Author Question: A client's nursing care plan includes assessment for auditory hallucinations. Indicators that ... (Read 60 times)

jerry coleman · **on:** Jul 19, 2018

A client's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest
the client may be hallucinating include

a. aloofness, haughtiness, and suspicion.
b. elevated mood, hyperactivity, and distractibility.
c. performing rituals and avoiding open places.
d. darting eyes, tilted head, and mumbling to self.

Question 2

A depressed client does not converse except when addressed, and then only in monosyllables. The
nurse wishes to show nonjudgmental acceptance and support for the client. This can best be done by

a. asking the client direct questions.
b. phrasing questions to require yes or no answers.
c. using platitudes to reduce guilt feelings.
d. stating observations.

milbourne11 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

D
Clues to hallucinations include eyes looking around the room as though to find the speaker; tilting
the head to one side as though listening intently; and grimacing, mumbling, or talking aloud as
though responding conversationally to someone.

Answer to Question 2

D
Making observations about neutral topics such as the environment draws the client into the reality
around him or her but places no burdensome expectations for answers on the client. Acceptance and
support are shown by the nurse's presence. Option A: Direct questions may make the client feel that
the encounter is an interrogation. Option B: Open-ended questions are preferable if the client is able
to participate in dialogue. Option C: Platitudes are never acceptable. They minimize client feelings
and can increase feelings of worthlessness.